I hereby request, consent and authorize Virtual Psychiatric Care (“VPC”) and its subsidiaries (MiamiPsych Concierge, LLC), affiliates, representatives, and agents (collectively, “VPC”) and their employed or contracted physicians, physician assistants, nurse practitioners or other licensed health care professionals in its care network (the “Practitioners”), to utilize telemedicine (or telehealth) through VPC’s proprietary systems, methods and protocols to access, diagnose, consult, treat and educate me and those I am authorized to represent (the “Services”).

I acknowledge and consent to see a Practitioner via telemedicine/telehealth. I understand that my eligibility to receive a visit via telemedicine is based on the Practitioner’s professional judgment that it is appropriate and that the quality of care will not be diminished by the use of telehealth. I understand that a telehealth visit is distinct from an in-person visit because I will not be in the same room as the health care Practitioner, and instead, I will communicate with the Practitioner through advanced communication technology using live video and audio feed.

I acknowledge that in order to protect my privacy, I need to choose a private location to place my telemedicine or telehealth call. I understand that in order to provide the best call environment, I should reduce background light from windows or light emanating from behind me. I understand that my camera should be placed on a secure, stable platform to avoid wobbling and shaking during the telemedicine session. To the extent possible, my camera should be placed at the same elevation as my eyes with my face clearly visible to the other person. I understand that I will be informed of the presence of any third party, including those that may be present to assist with the audio or video equipment, and that I have the right to: (1) omit specific details of medical history or physical examination that are sensitive to me during such third party presence, (2) ask non-medical personnel to leave the telehealth examination room, and/or (3) terminate the consultation at any time by notifying the Practitioner or disconnecting from the telehealth portal.

I understand the potential risks of receiving the Services via telehealth include: delays in medical evaluation due to technological equipment failure, a lack of access to all relevant information, or a security breach allowing unauthorized access to my confidential medical information. I understand that my Practitioner or I may terminate the telehealth visit at any time, including if the Practitioner or I feel that an in-person visit is necessary for any reason. I have had the Services and alternatives to telehealth for my Services explained to me and I choose to and continue with a telemedicine visit.

I understand that any complaint may be filed with the Secretary of the Department of Health and Human Services.

I have read and understood the written information provided above. I agree that the information provided above adequately explains the Services, along with the risks and benefits to me of said Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full. By electronically signing this form, I acknowledge and agree to all of the above, and certify that I have no questions and/or have had my questions answered in full.

By electronically signing this informed consent, I am agreeing to conduct transactions electronically, and intend for my electronic signature to be a binding electronic signature on myself and those I am authorized to represent. Further, I understand and acknowledge that I am digitally receiving a copy of this Agreement concurrently upon execution to print and/or retain a copy of this Agreement, and may also request a paper copy from VPC using the contact information below:

If you have any questions, please contact support@virtualpsychiatriccare.com

Patient medication history is a list of prescriptions that your healthcare providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.

 

The collected information is stored in the practice electronic medical record system and becomes part of your personal medical record. Medication history is very important in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.

 

It is very important that you and your provider discuss all your medications in order to ensure that your recorded medication history is 100% accurate. Some pharmacies do not make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.

 

Also, over‐the‐counter drugs, supplements, or herbal remedies that you take on your own may not be included.

 

I give permission to allow Virtual Psychiatric Care (a subsidiary of MiamiPsych Concierge, LLC) Practitioners to obtain my medication history from my pharmacy, my health plans, electronically via prescription monitoring programs, and my other healthcare providers.

 

 By electronically signing this consent form you are giving your healthcare provider permission to collect and share your pharmacy and your health insurer information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health issues such as depression.